Diffusion-weighted magnetic resonance imaging for predicting the response of rectal cancer to neoadjuvant concurrent chemoradiation

AIM:To evaluate the clinical value of diffusion-weighted magnetic resonance imaging(DW-MRI)in predicting the response of rectal cancer to neoadjuvant chemoradiation.METHODS:This prospective study was approved by our institutional review board,and informed consent was obtained from each patient.Fifteen patients(median age 56 years)with locally advanced rectal cancer were treated in our hospital from June 2006 to December 2007.All patients were stageⅢB-C according to the results of MRI and endorectal ultrasound examinations.All patients underwent pelvic irradiation with 45 Gy/25 fx per 35 days.The concurrent chemotherapy regimen consisted of capecitabine 625mg/m2,bid(Monday-Friday),and oxaliplatin 50 mg/m2,weekly.The patients underwent surgery 5-8 wk after the completion of neoadjuvant therapy.T downstaging was defined as the downstaging of the tumor from cT3to ypT0-2 or from cT4 to ypT0-3.Good regression was defined as TRG 3-4,and poor regression was defined as TRG 0-2.Diffusion-weighted magnetic resonance images were obtained prior to and weekly during the course of neoadjuvant chemoradiation,and the apparent diffusion coefficient(ADC)values were calculated from the acquired tumor images.RESULTS:Comparison with the mean pretreatment tumor ADC revealed an increase in the mean tumor ADC during the course of neoadjuvant chemoradiation,especially at the 2ndweek(P=0.004).We found a strong negative correlation between the mean pretreatment tumor ADC and tumor regression after neoadjuvant chemoradiation(P=0.021).In the T downstage and tumor regression groups,we found a significant increase in the mean ADC at the 2ndweek of neoadjuvant therapy(P=0.011;0.004).CONCLUSION:DW-MRI might be a valuable clinical tool to help predict or assess the response of rectal cancer to neoadjuvant chemoradiation at an early timepoint.

Routine defunctioning stoma after chemoradiation and total mesorectal excision:A single-surgeon experience

AIM:To investigate the 10-year results of treating low rectal cancer by a single surgeon in one institution.METHODS:From Oct 1998 to Feb 2009,we prospectively followed a total of 62 patients with cT2-4 low rectal cancer with lower tumor margins measuring at 3 to 6 cm above the anal verge.All patients received neoadjuvant chemoradiation(CRT) for 6 wk.Among them,85% of the patients received 225 mg/m2/d 5-fluorouracil using a portable infusion pump.The whole pelvis received a total dose of 45 Gy of irradiation in 25 fractions over 5 wk.The interval from CRT completion to surgical intervention was planned to be approximately 6-8 wk.Total mesorectal excision(TME) and routine defunctioning stoma construction were performed by one surgeon.The distal resection margin,circumferential resection margin,tumor regression grade(TRG) and other parameters were recorded.We used TRG to evaluate the tumor response after neoadjuvant CRT.We evaluated anal function outcomes using the Memorial Sloan-Kettering Cancer Center anal function scores after closure of the defunctioning stoma.RESULTS:The median distance from the lower margin of rectal cancer to the anal verge was 5 cm:6 cm in 9 patients,5 cm in 32 patients,4 cm in 10 patients,and 3 cm in 11 patients.Before receiving neoadjuvant CRT,45 patients(72.6%) had a cT3-4 tumor,and 21(33.9%) patients had a cN1-2 lymph node status.After CRT,30 patients(48.4%) had a greater than 50% clinical reduction in tumor size.The final pathology reports revealed that 33 patients(53.2%) had a ypT3-4 tumor and 12(19.4%) patients had ypN1-2 lymph node involvement.All patients completed the entire course of neoadjuvant CRT.Most patients developed only Grade 1-2 toxicities during CRT.Thirteen patients(21%) achieved a pathologic complete response.Few post-operative complications occurred.Nearly 90% of the defunctioning stomas were closed within 6 mo.The local recurrence rate was 3.2%.Pathologic lymph node involvement was the only prognostic factor predicting disease recurrence(36.5% vs 76.5%,P = 0.006).Nearly 90% of patients recovered sphincter function within 2 year after closure of the defunctioning stoma.CONCLUSION:Neoadjuvant CRT followed by TME,combined with routine defunctioning stoma construction and high-volume surgeon experience,can provide excellent surgical quality and good local disease control.

Neoadjuvant treatment for advanced esophageal cancer: response assessment before surgery and how to predict response to chemoradiation before starting treatment

Patients with advanced esophageal cancer（T3-4, N） have a poor prognosis. Chemoradiation or chemotherapy before esophagectomy with adequate lymphadenectomy is the standard treatment for patients with resectable advanced esophageal carcinoma. However, only patients with major histopathologic response（regression to less than 10% of the primary tumor） after preoperative treatment will have a prognostic benefit of preoperative chemoradiation. Using current therapy regimens about 40% to 50% of the patients show major histopathological response. The remaining cohort does not benefit from this neoadjuvant approach but might benefit from earlier surgical resection. Therefore, it is an aim to develop tools for response prediction before starting the treatment and for early response assessment identifying responders. The current review discusses the different imaging techniques and the most recent studies about molecular markers for early response prediction. The results show that [^18F]-fluorodeoxyglucose-positron emission tomography（FDGPET） has a good sensitivity but the specificity is not robust enough for routine clinical use. Newer positron emission tomography detector technology, the combination of FDG-PET with computed tomography, additional evaluation criteria and standardization of evaluation may improve the predictive value. There exist a great number of retrospective studies using molecular markers for prediction of response. Until now the clinical use is missing. But the results of first prospective studies are promising. A future perspective may be the combination of imaging technics and special molecular markers for individualized therapy. Another aspect is the response assessment after finishing neoadjuvant treatment protocol. The different clinical methods are discussed. The results show that until now no non-invasive method is valid enough to assess complete histopathological response.

Preoperative chemoradiation and extended pelvic lymphadenectomy for rectal cancer:Two distinct principles

Extended pelvic lymphadenectomy(EPL) with total mesorectal excision(TME) has been reported to provide oncological benefit in lower rectal cancer in Japan.In Western countries EPL is not widely accepted because of frequent morbidity but instead preoperative chemoradiation(CRT) followed by TME has been established as a standard treatment for decreasing local recurrence.Recently,several studies have focused on the comparison between these two distinct therapeutic approaches in Western countries and Japan.A study comparing Dutch trial data and Japanese data revealed that EPL and RT are almost equivalent in decreasing local recurrence in lower rectal cancer as compared with TME alone.Considering that almost 45 survival can be achieved by EPL even in the presence of metastatic lateral lymph nodes(LLNs),EPL performed by experienced surgeons definitely contributes to decrease local recurrence.On the other hand,a randomized controlled trial in Japan that compared EPL with conventional TME following preoperative RT revealed that EPL is associated with a higher frequency of sexual and urinary dysfunction without oncological benefits in the presence of preoperative RT.On this point,preoperative CRT followed by conventional TME without EPL would be a better therapeutic approach in patients without evident metastatic LLNs.For future treatment,it would be desirable to have a narrower indication for EPL using full advantage of recent improvement in image diagnosis.Although objective comparison of these two principles between Japan and the West is difficult due to differences in patient groups,further studies would lead to the next great step towards future improvement in treating lower rectal cancer.

Arterio-biliary fistula as rare complication of chemoradiation therapy for intrahepatic cholangiocarcinoma

Significant hemobilia due to arterio-biliary fistula is a very rare complication of chemoradiation therapy(CRT) for unresectable intrahepatic cholangiocarcinoma(ICC).Here we report a case of arterio-biliary fistula after CRT for unresectable ICC demonstrated by angiographic examinations.This fistula was successfully treated by endovascular embolization.Hemobilia is a rare complication,but arterio-biliary fistula should be considered after CRT of ICC.

High-dose-rate intraluminal brachytherapy during preoperative chemoradiation for locally advanced rectal cancers

AIM:To determine the feasibility and safety of high dose rate intraluminal brachytherapy(HDR-ILBT) boost during preoperative chemoradiation for rectal cancer.METHODS:Between 2008 and 2009,thirty-six patients with locally advanced rectal cancer(≥ T3 or N+),were treated initially with concurrent capecitabine(825 mg/m2 oral twice daily) and pelvic external beam radiotherapy(EBRT)(45 Gy in 25 fractions),then were randomized to group A;HDR-ILBT group(n = 17) to receive 5.5-7 Gy×2 to gross tumor volume(GTV) and group B;EBRT group(n = 19) to receive 5.4 Gy×3 fractions to GTV with EBRT.All patients underwent total mesorectal excision.RESULTS:Grade 3 acute toxicities were registered in 12 patients(70.6%) in group A and in 8(42.1%) in group B.Complete pathologic response of T stage(ypT0) in group A was registered in 10 patients(58.8%) and in group B,3 patients(15.8%) had ypT0(P < 0.0001).Sphincter preservation was reported in 6/9 patients(66.7%) in group A and in 5/10 patients(50%) in group B(P < 0.01).Overall radiological response was 68.15% and 66.04% in Group A and B,respectively.During a median follow up of 18 mo,late grade 1 and 2 sequelae were registered in 3 patients(17.6%) and 4 patients(21.1%) in the groups A and B,respectively.CONCLUSION:HDR-ILBT was found to be effective dose escalation technique in preoperative chemoradiation for rectal cancers,with higher response rates,downstaging and with manageable acute toxicities.

Chemoradiation as definitive treatment for primary squamous cell cancer of the rectum

In this report,we present a case of advanced squamous cell cancer located in the rectum of a 78-year-old woman treated with chemoradiation with curative intent.The patient showed a complete clinical response to chemoradiation;multiple biopsies were performed at the site of the previous mass 5 mo after the end of treatment and histological examination showed no residual tumour in the specimens.Surgical intervention was avoided and the patient was free of disease 12 mo after the diagnosis of cancer.Primary chemoradiation should be considered as the treatment of choice for this rare malignancy.

Intensity modulated radiation therapy with simultaneous integrated boost based dose escalation on neoadjuvant chemoradiation therapy for locally advanced distal esophageal adenocarcinoma

AIM:To evaluate impact of radiation therapy dose escalation through intensity modulated radiation therapy with simultaneous integrated boost(IMRT-SIB).METHODS:We retrospectively reviewed the patients who underwent four-dimensional-based IMRT-SIBbased neoadjuvant chemoradiation protocol.During the concurrent chemoradiation therapy,radiation therapy was through IMRT-SIB delivered in 28 consecutive daily fractions with total radiation doses of 56 Gy to tumor and 5040 Gy dose-painted to clinical tumor volume,with a regimen at the discretion of the treating medical oncologist.This was followed by surgical tumor resection.We analyzed pathological completion response(p CR) rates its relationship with overall survival and event-freesurvival.RESULTS:Seventeen patients underwent dose escalation with the IMRT-SIB protocol between 2007 and 2014 and their records were available for analysis.Among the IMRT-SIB-treated patients,the toxicity appeared mild,the most common side effects were grade 1-3 esophagitis(46%) and pneumonitis(11.7%).There were no cardiac events.The Ro resection rate was 94%(n = 16),the p CR rate was 47%(n = 8),and the postoperative morbidity was zero.There was one mediastinal failure found,one patient had local failure at the anastomosis site,and the majority of failures were distant in the lung or bone.The 3-year diseasefree survival and overall survival rates were 41%(n = 7) and 53%(n = 9),respectively.CONCLUSION:The dose escalation through IMRT-SIB in the chemoradiation regimen seems responsible for down-staging the distal esophageal with well-tolerated complications.

Concurrent chemoradiation for high-risk prostate cancer

There are estimated to be 220800 cases of prostate cancer diagnosed in 2015, making up 26% of all cancer diagnoses. Fortunately, adenocarcinoma of the prostate is often a highly treatable malignancy. Even though the majority of prostate cancer patients present with localized disease, prostate cancer still accounts for over 27000 deaths a year. There is a subset of patients thatare likely to recur after locoregional treatment that is thought of as a "high-risk" population. This more aggressive subset includes patients with clinical stage greater than T2 b, Gleason score greater than 7, and prostate specific antigen greater than 20 ng/d L. The rate of biochemical relapse in this high risk group is 32%-70% within five years of definitive focal therapy. Given these discouraging outcomes, attempts have been made to improve cure rates by radiation dose escalation, addition of androgen depravation therapy, and addition of chemotherapy either sequentially or concurrently with radiation. One method that has been shown to improve clinical outcomes is the addition of chemotherapy to radiotherapy for definitive treatment. Concurrent chemoradiation with 5-fluorouracil, estramustine phosphate, vincristine, docetaxel, and paclitaxel has been studied in the phase I and/or II setting. These trials have identified the maximum tolerated dose of chemotherapy and radiation that can be safely delivered concurrently and established the safety and feasibility of this technique. This review will focus on the addition of concurrent chemotherapy to radiotherapy in the definitive management of high-risk prostate cancer.

Capecitabine and Oxaliplatin versus 5-Fluorouracil in the Neoadjuvant Chemoradiation for Patients with Locally Advanced Rectal Carcinoma: A Comparative Study

Aim of work: This study aimed to evaluate the resectability rate, rate of conservative surgery, toxicity, local control, and disease free survival for oxaliplatin and capecitabine based chemoradiation compared to standard 5-FU based chemoradiation in locally advanced cancer rectum. Patients and methods: 65 patients were eligible;33 patients received oxaliplatin and capecitabine based chemoradiation (arm I) and 32 patients received 5-FU based chemoradiation (arm II). Results: The overall response rate in arms I and II were 78.7% and 87.5% respectively. Conservative surgery was done in 81.81% and 53.13% of patients with arms I and II, pathologic complete response (pCR) rate was significantly better in arm I than arm II (30.3% vs. 21.9%, P < 0.01). 3-year recurrence rates were 54.5% and 56.2% in arms I, II respectively;the median disease free survival (DFS) were 30 months and 15 months in arms I and II respectively. Grade III anemia, grade IV diarrhea and severe proctitis were developed in a significantly large number of patients with arm I;in addition deep venous thrombosis (DVT) was developed in 15.15% of patients with arm I but none in arm II. Conclusion: The addition of oxaliplatin to the preoperative chemo radiation increased the response rate mainly pCR rate which was considered a target goal in the neoadjuvant treatment, but it was not recommended because of higher toxicity and no significant effect on DFS in different response groups of arm I when compared to arm II, but longer follow up may be needed to evaluate the overall survival.

Nimotuzumab with Concurrent Chemoradiation in Inoperable Locally Advanced Squamous Cell Carcinoma of Head and Neck: An Indian Experience

Background: The prognosis of patients with Epidermal Growth Factor Receptor (EGFR) overexpression in inoperable Locally Advanced Squamous Cell Carcinoma of Head and Neck (LASCCHN) remains poor. Nimotuzumab is an Anti EGFR humanized monoclonal antibody approved for treatment of LASCCHN, with concurrent chemoradiation. Objective: To assess the efficacy and safety of nimotuzumab with concurrent chemoradiation in inoperable LASCCHN patients. Methodology: This is a single-centre, single arm, retrospective study evaluating 35 patients with histologically confirmed inoperable LASCCHN (stages III-IV). The patients were administered IV cisplatin 50 mg/m2 and IV nimotuzumab 200 mg for 6 - 7 weeks, along with radiotherapy of 6600 - 7000 cGy over 35 fractions. Patients were evaluated over response evaluation criteria in solid tumors (RECIST) criteria 12 weeks after the last cycle of chemotherapy. They were also followed up for overall survival and relapse free survival. Results: The median duration of follow-up was 20 months. The most common site of cancer was oropharynx (68.6%). One patient was lost to follow up. Objective Response Rate (ORR) was observed in 97% of the patients with 17 patients (48.6%) achieving complete response (CR) and 17 patients (48.6%) achieving partial response (PR). The median overall survival was 22.7 months (95% CI: 21.30, 34.27). The median relapse free survival was 16.7 months (95% CI: 9.80, 24.50). Nimotuzumab was safe and well tolerated with few mild, self-limiting adverse events. Conclusion: Nimotuzumab with chemoradiation is a safe and efficacious option in patients with LASCCHN. Larger studies are needed to verify the same.

Nutritional Management of Cancer Patients Undergoing Chemotherapy and Chemoradiation Therapy

Although chemotherapy and chemoradiation therapy improve the clinical outcomes and decrease locoregional failure in patients with advanced cancer, they may lead to an increased risk of malnutrition in these patients due to their gastrointestinal side effects. Many cancer patients are already malnourished as a result of their cancer-bearing status. Consequently, these patients experience poor clinical outcomes due to various infectious and noninfectious complications. Nutritional management that is based on frequent monitoring of the nutritional status of patients can ensure that they receive adequate calories and certain nutrients, which is vital to improve their clinical outcomes and quality of life.

Portal vein stenosis after pancreatectomy following neoadjuvant chemoradiation therapy for pancreatic cancer

Extrahepatic portal vein (PV) stenosis has various causes, such as tumor encasement, pancreatitis and as a postsurgical complication. With regard to post-pancreaticoduodenectomy, intraoperative radiation therapy with/ without PV resection is reported to be associated with PV stenosis. However, there has been no report of PV stenosis after pancreatectomy following neoadjuvant chemoradiation therapy (NACRT). Here we report the cases of three patients with PV stenosis after pancreatectomy and PV resection following gemcitabine-based NACRT for pancreatic cancer and their successful treatment with stent placement. We have performed NACRT in 18 patients with borderline resectable pancreatic cancer since 2005. Of the 15 patients who completed NACRT, nine had undergone pancreatectomy. Combined portal resection was performed in eight of the nine patients. We report here three patients with PV stenosis, and thus the ratio of post-operative PV stenosis in patients with PV resection following NACRT is 37.5% in this series. We encountered no case of PV stenosis among 22 patients operated with PV resection for pancreatobiliary cancer without NACRT during the same period. A relationship between PV stenosis and NACRT is suspected, but further investigation is required to determine whether NACRT has relevance to PV stenosis.

Endoscopic ultrasound-guided fiducial marker placement for neoadjuvant chemoradiation therapy for resectable pancreatic cancer

BACKGROUND Preoperative neoadjuvant chemoradiation therapy(NACRT)is applied for resectable pancreatic cancer(RPC).To maximize the efficacy of NACRT,it is essential to ensure the accurate placement of fiducial markers for image-guided radiation.However,no standard method for delivering fiducial markers has been established to date,and the nature of RPC during NACRT remains unclear.AIM To determine the feasibility,safety and benefits of endoscopic ultrasound-guided(EUS)fiducial marker placement in patients with RPC.METHODS This was a prospective case series of 29 patients(mean age,67.5 years;62.1%male)with RPC referred to our facility for NACRT.Under EUS guidance,a single gold marker was placed into the tumor using either a 19-or 22-gauge fine-needle aspiration needle.The differences in daily marker positioning were measured by comparing simulation computed tomography and treatment computed tomography.RESULTS In all 29 patients(100%)who underwent EUS fiducial marker placement,fiducials were placed successfully with only minor,self-limiting bleeding during puncture observed in 2 patients(6.9%).NACRT was subsequently administered to all patients and completed in 28/29(96.6%)cases,with one patient experiencing repeat cholangitis.Spontaneous migration of gold markers was observed in 1 patient.Twenty-four patients(82.8%)had surgery with 91.7%(22/24)R0 resection,and two patients experienced complete remission.No inflammatory changes around the marker were observed in the surgical specimen.The daily position of gold markers showed large positional changes,particularly in the superior-inferior direction.Moreover,tumor location was affected by food and fluid intake as well as bowel gas,which changes daily.CONCLUSION EUS fiducial marker placement following NACRT for RPC is feasible and safe.The RPC is mobile and is affected by not only aspiration,but also food and fluid intake and bowel condition.

Esophagogastric junction adenocarcinoma:Preoperative chemoradiation or perioperative chemotherapy?

Multimodal treatment is currently the standard of care for locally advanced esophagogastric junction(EGJ)adenocarcinoma due to poor results after surgery alone.Neoadjuvant therapy is intended to shrink the tumor and eliminate potential circulating tumor cells.However,which neoadjuvant treatment is best for patients with EGJ tumors remains controversial.We aimed to compare outcomes of preoperative chemoradiation and perioperative chemotherapy for EGJ adenocarcinomas.For this purpose,we performed a thorough review of the literature describing neoadjuvant treatments for EGJ adenocarcinomas or comparing both therapies.Although some studies have shown better locoregional control and higher rates of complete pathologic response after chemoradiation,data suggest that both types of neoadjuvant therapy have similar survival benefits.As current data are heterogeneous and many studies have included significantly different types of patients in their analysis,future studies with better patient selection are still needed to define which neoadjuvant therapy should be chosen.In addition,targeted therapies and immunotherapy have promising results and should be further explored.

Sphincter Saving Surgeries for Locally Advanced Low Rectal Cancer after Neoadjuvant Chemoradiation

Background: Rectal cancer accounts for the largest distribution within one anatomical region of the large bowel, with approximately one third of all CRC located within the rectum. The Golden standard treatment of primary rectal cancer is curative surgical resection;however, a fine balance remains between disease cure and restoration of gastrointestinal continuity. Combined modality has proven efficacy in many malignant tumors with advantage of organ preservation. Methods: Forty nine (49) patients with low rectal carcinoma were included in a prospective study, between Jan 2007 and Jan 2012. Preoperative chemoradiation was administrated to all patients and subjected to different techniques of sphincter saving surgery. Stage I and Stage IV disease at diagnosis were excluded from the study. Results: Forty nine patients were included in the study. 27 (55%) patients were male and 22 (45%) were female;the age ranges from 23 years to 70 years with the median age 46 years. The main presenting symptoms were bleeding per rectum and tenesmus, Stage II 18 patients (36.7%), stage III 31 patients (63.3%). Complete clinical and pathological response in 3 patients (6%), and complete clinical response with only microscopically residual carcinoma in 20 patients (41%), partial response in 18 patients (36.7%), and no significant response in 8 patients (16%) 7 from 8 were mucoid carcinoma. Low anterior resection (LAR) in 22 patients (44.9%), Hartman’s procedure in 4 patients (8.1%), Coloanal pull-through (COP) was done in 19 patients (38.9%) and perineal colostomy in 4 patients (8.1%). For patients with colo-anal pull-through technique complete dehiscent and retraction observed in 2 cases, Major leakage in one case, stenosis in 4 cases. Conclusion: There is tendency of colorectal cancers to affect younger groups. Most patients presented in advanced stage. Neadjuvant chemo radiation is an excellent tool in sphincter saving surgery. Coloanal pull-through technique is not a widely spread technique for low rectal cancer with good oncological safety and acceptable functional outcome.

Unusual Case of Radiation Induced Balanitis after Chemoradiation for Upper Rectal Adenocarcinoma

Background: Penile toxicity after preoperative concurrent chemoradiation (CCRT) for rectal cancers is extremely rare and only two cases of phimosis and one case of recto-cavernosalfistula have been reported so far in literature. Preoperative CCRT for rectal cancer is given in prone position and with the support of belly board (BBD) to avoid small bowel toxicity. However, positional errors during rectal radiotherapy can lead to unexpected penile toxicity. Case Presentation: A 50-year-old Saudi male with diagnosed case of rectal adenocarcinoma stage cT3N1M0 was given preoperative CCRT 50.4 Gy in 28 fractions with three-dimensional conformal radiation therapy (3DCRT) in prone position using belly board with concurrent oral capecitabine 825 mg/2 twice a day. After the completion of CCRT, he complained of severe soreness, itching over glans penis and dysuria. Examination revealed grade 3 erythema, skin desquamation over glans penis (balanitis). Portal imaging of treatment revealed glans penis to lie within posterior radiation beam. A patient was assured and he recovered fully after local steroids and short course of antibiotics. Conclusion: Penile toxicity after CCRT for rectal cancer is extremely rare manifestation. Radiation oncologists and therapists must be aware of this rare side effect and must assure proper patient education and positioning during CCRT for rectal cancer.

Intravenous Fluorouracil versus Oral Capecitabine: Postoperative Chemoradiation for Gastric Cancer

Purpose: Aim of this prospective, phase III trial was to compare the efficacy and toxicity of intravenous fluorouracil and oral capecitabine when given concurrently with radiation in adjuvant sitting for adenocarcinoma of the stomach after gastrectomy with D2 resection. Patients and Method: The study included 60 patients having histologically proven adenocarcinoma of the stomach or gastroesophageal junction;stage T2-4 N0-3 M0 after gastrectomy with D2 lymph node dissection. Eligible patients were randomly assigned to receive adjuvant radiotherapy concurrently with intravenous fluorouracil [arm A] or oral capecitabine [arm B]. Results: Ten patients cannot complete their whole treatment course because of either progressive [4 patients;2 arm A and 2 arm B] or G 3 toxicity [1 patient] or refuse to complete their treatment [5 patients;3 arm A and 2 arm B]. Patients received fluorouracil have significant increase grade 3 or 4 hematological [neutropenia] and gastrointestinal (diarrhoea, anorexia, and vomiting). During a median follow-up period of 24 months, the 2-year disease free and overall survivals in this study were 60% and 63.3%, for groups A and B respectively, while overall survival were 63.3% and 70% for groups A and B respectively without significant differences. Conclusion: Oral capecitabine concurrently with radiation therapy has comparable efficacy and favourable toxicity profile when compared to infusion fluorouracil as postoperative adjuvant therapy for gastric adenocarcinoma.

Concomitant Chemoradiation Using Gemcitabine in Locally Advanced Hepatocellular Carcinoma

Purpose: Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide. Most of patients present with advanced disease that cannot be treated with curative or ablative intent. The aim of the study was to assess the therapeutic benefit of concurrent chemoradiotherapy (CCRT) in patients with advanced HCC and to identify factors that predict OS. Methods: Patients with radiologically or biopsy proven primary HCC from 2010 to 2013 were included in the study. Gemcitabine was given in a dose of 70 mg/m2 once weekly for three weeks during external beam radiotherapy 30 Gy/2 Gy/fraction/five fractions per week in the Clinical Oncology Department, Assiut, Egypt. Results: Forty-nine patients were eligible but forty patients were evaluable for assessment. The partial response rate (PR) was 35% (14 patients), 16 patients (40%) had stable disease (SD) and the progressive disease was 25%. Painful hepatomegaly was significantly relieved in 70% of patients. Transaminases rose as grade 3 toxicity in 15% of patients. Longer overall survival (OS) was significantly observed in patients with performance status 0, child-Pugh A, Barcelona Clinic Liver cancer Stage B, PR and α fetoprotein level decrement. Conclusion: Concurrent chemoradiotherapt provides an acceptable response and palliation of pain in advances HCC. Our findings showed that better survival for patients with good performance and liver functions.

Radiation therapy prior to a pancreaticoduodenectomy for adenocarcinoma is associated with longer operative times and higher blood loss

BACKGROUND Pancreatic adenocarcinoma is currently the fourth leading cause of cancer-related deaths in the United States.In patients with“borderline resectable”disease,current National Comprehensive Cancer Center guidelines recommend the use of neoadjuvant chemoradiation prior to a pancreaticoduodenectomy.Although neoadjuvant radiotherapy may improve negative margin resection rate,it is theorized that its administration increases operative times and complexity.AIM To investigate the association between neoadjuvant radiotherapy and 30-d morbidity and mortality outcomes among patients receiving a pancreaticoduodenectomy for pancreatic adenocarcinoma.METHODS Patients listed in the 2015-2019 National Surgery Quality Improvement Program data set,who received a pancreaticoduodenectomy for pancreatic adenocarcinoma,were divided into two groups based off neoadjuvant radiotherapy status.Multivariable regression was used to determine if there is a significant correlation between neoadjuvant radiotherapy,perioperative blood transfusion status,total operative time,and other perioperative outcomes.RESULTS Of the 11458 patients included in the study,1470(12.8%)underwent neoadjuvant radiotherapy.Patients who received neoadjuvant radiotherapy were significantly more likely to require a perioperative blood transfusion[adjusted odds ratio(aOR)=1.58,95%confidence interval(CI):1.37-1.82;P<0.001]and have longer surgeries(insulin receptor-related receptor=1.14,95%CI:1.11-1.16;P<0.001),while simultaneously having lower rates of organ space infections(aOR=0.80,95%CI:0.66-0.97;P=0.02)and pancreatic fistula formation(aOR=0.50,95%CI:0.40-0.63;P<0.001)compared to those who underwent surgery alone.CONCLUSION Neoadjuvant radiotherapy,while not associated with increased mortality,will impact the complexity of surgical resection in patients with pancreatic adenocarcinoma.